What is the role of advanced practice nurses and physician assistants in the ICU?

86 What Is the Role of Advanced Practice Nurses and Physician Assistants in the ICU? Ruth Kleinpell and W. Robert Grabenkort

It is estimated that more than 5.7 million patients are admitted annually to intensive care units (ICUs) in the United States for intensive or life-sustaining treatments for acute and critical care conditions. Additionally, approximately 20% of acute care admissions are to an ICU and up to 58% of emergency department admissions result in an ICU admission.1 Research indicates that the demand will create a 35% shortfall of intensivist hours by 2020.1,2 One strategy for meeting ICU workforce needs is the addition of advanced practice professionals to ICU teams.3,4 Advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs), are an increasingly important component of the nation’s healthcare workforce. More than 370,000 (.250,000 NPs and .120,000 PAs) practice in the US health-care system.5,6 Consistent with the Institute of Medicine’s report,7 NPs and PAs play a vital role in delivering patient care, promoting multiprofessional collaboration, and advancing team approaches to care. These clinicians provide primary, acute, and specialty care services to patients in countless acute and nonacute care settings.

NURSE PRACTITIONER AND PHYSICIAN ASSISTANT ROLES NPs are registered nurses who are prepared at either the master’s or doctoral level, have an independent license, and are required to pass a national certification examination in most states to practice. NPs practice autonomously in most states with a scope of practice that is dependent on education, licensure, certification, and program accreditation. To be in compliance with the National Council of State Boards of Nursing’s recommendations for the Advanced Practice Registered Nurse Consensus Model for practice in the ICU setting, NPs should be certified in either acute care or adult gerontology acute care.8 Similarly, PAs are health-care professionals who are certified by a national examination process. Most PAs are prepared at the graduate level, but some have bachelor’s degrees.6 PAs are state-licensed health-care professionals who practice under the supervision of a sponsoring physician who must be available for consultation by phone or in person.6 618

NPs and PAs often have similar roles in the ICU, but in some settings differences exist. PAs focus on direct medical management or surgical assistance, whereas NP care encompasses direct patient care in addition to continuity of care components such as discharge planning; nursing, patient, and family education; and quality improvement/research, among with other additional duties (Table 86.1).9–11

USE OF NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS IN THE ICU Data from national surveys on the use of NPs and PAs indicate that utilization in hospital settings has increased because of the higher acuity of hospitalized patients, restrictions placed on medical resident work hours, the need for continuity of care, and workforce shortages.12 In university-based hospital settings where the new Accreditation Council for Graduate Medical Education duty-hour regulations for physicians in training have been implemented, the integration of NPs and PAs into multidisciplinary provider models represents a solution to the gap in coverage.12 A study of 25 academic medical centers indicated that an additional role for NP and PA care has resulted from the need for improved access, improved continuity of care, patient throughput, and medical resident training restrictions, among others (Fig. 86.1).12 Role components of NPs and PAs in the ICU are detailed in Box 86.1.13 Several studies have linked improved quality and reduced costs to the participation of NPs and PAs in care (Table 86.2). Because ICU care is often team based, assessing the impact of NPs and PAs in the ICU can be difficult. However, several studies have demonstrated that NP- and PA-provided care resulted in improved outcomes (Box 86.2).14–26 On the basis of reports of established and developing models of care with NPs and PAs and research demonstrating their effectiveness, the use of NPs and PAs in the ICU is now a recognized solution to workforce challenges in managing critically ill patients.27 Integrating NPs and PAs in the ICU can help to facilitate the delivery of high-quality medical care and can provide continuity of care. NPs and PAs can become important elements of multiprovider ICU teams.28

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TABLE 86.1  NP and PA Role Comparisons. Category

PA

NP

Definition

Health-care professionals licensed to practice medical care with physician supervision. Currently, the American Academy of Physician Assistants (AAPA) is exploring the Optimal Team Practice model, which does not require the establishment of a specific, sponsoring physician

Registered nurses with advanced education and training who have an independent license

Philosophy/model

Medical/physician model, disease centered, with Medical/nursing model, biopsychosocial cenemphasis on the biological/pathologic aspects of tered, with emphasis on disease adaptation, health, assessment, diagnosis, treatment. Practice health promotion, wellness, and prevention. model is a team approach relationship with Practice model is a collaborative relationship physicians with physicians

Education

Affiliated with medical schools. Previous health-care Affiliated with nursing schools. BSN is prerequisite and education is at master’s or doctoral experience required; most require entry-level level; curriculum is biopsychosocial based, bachelor’s degree. The program curriculum is advanced science based. Approximately 2000 clini- based on behavioral, natural, and humanistic sciences. Approximately 750 to 1000 clinical cal hours. All PAs are trained as generalists. hours. NPs choose a specialty training track in Education is procedure and skill oriented with adult, acute care, pediatric, women’s health, or emphasis on diagnosis, treatment, surgical skills, gerontology and patient education. Currently, most programs award master’s degrees and the remaining programs are currently transitioning to the master’s level. Some graduate PAs elect to receive optional, advanced postgraduate specialty training in areas such as critical care medicine

Certification/licensure

Separate accreditation and certification bodies require successful completion of an accredited program and NCCPA national certification exam

National certification is required in the majority of states

Recertification

Recertification requires 100 hours of CME every 2 years and an exam every 10 years. All PAs are licensed by their State Medical Board and the Medical Practice Act provisions

Recertification requires, on average, 75 CEUs every 5–6 years. NPs are licensed by their State Board of Nursing

Scope of practice

NP scope of practice is based on licensure, The supervising physician has relatively broad accreditation, certification, and education. NPs discretion in delegating medical tasks within his/ her scope of practice to the PA in accordance with have independent practice in the majority of states; some states have physician collaborastate regulations. Prescriptive privileges vary by tion requirements. NPs may prescribe consponsoring physician specialty and state regulatrolled substances. On-site supervision is not tions. On-site supervision is not required required

Third-party coverage and reimbursement

PAs are eligible for certification as Medicaid and NPs are eligible for certification as Medicaid and Medicare providers. Commercial payer reimburseMedicare providers and generally receive favorable reimbursement from commercial ment is currently variable but is being promoted payers by the AAPA for improved payer consistency

BSN, bachelor of science in nursing; CEU, continuing education unit; CME, continuing medical education; NCCPA, National Commission on Certification of Physician Assistants; NP, nurse practitioner; PA, physician assistant. Adapted from Maryland Academy of Physician Assistants and American Academy of Physician Assistants. www.mdapa.org/maryland/differences.asp.

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Critical Care Resource Use and Management MD time for nonclinical duties Reduce LOS Improve continuity Physician productivity Patient throughput Improve access ACGME limits 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Other Primary

Fig. 86.1  ​Reasons for Hiring Nurse Practitioners and Physician Assistants as Reported by 25 Academic Medical Centers. ACGME, Accreditation Council for Graduate Medical Education; LOS, length of stay; MD, medical doctor. (Adapted from Moote et al.11)

BOX 86.1  Roles of NPs and PAs in the ICU. Patient care management Rounding Obtaining history and performing physical examinations Diagnosing and treating illnesses Ordering and interpreting tests Initiating orders, often under protocols Prescribing and performing diagnostic, pharmacologic, and therapeutic interventions consistent with education, practice, and state regulations Performing procedures (as credentialed and privileged, such as arterial line insertion, suturing, and chest tube insertion) Assessing and implementing nutrition Collaborating and consulting with the interdisciplinary team, patient, and family Surgical assisting in the operating room Education of staff, patients, and families

Practice guideline implementation Lead, monitor, and reinforce practice guidelines for ICU patients (e.g., central line insertion procedures, infection prevention measures, stress ulcer prophylaxis) Clinical research Data collection Enrollment of subjects Research study management Quality assurance Lead quality-assurance initiatives such as ventilator-associated pneumonia bundle, sepsis bundle, rapid response team Communication Promote and enhance communication with ICU staff, family members, and the multidisciplinary team Discharge planning Transfer and referral consultations Patient and family education regarding anticipated plan of care

ICU, intensive care unit, NP, nurse practitioner, PA, physician assistant. Adapted from Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med. 2008;36(10):2888-2897..

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TABLE 86.2  Selected Studies on NP and PA Care in the ICU. Study

Method/Focus

Gershengorn et al., 201123

Retrospective review of 590 daytime admissions to 2 No significant difference in hospital mortality, ICU MICUs with use of NPs and PA coverage LOS, or hospital LOS. Discharge to a skilled care facility was similar for NP/PA care compared with medical resident care

Main Results

Gershengorn et al., 201214

Literature review of the use of NP and PA providers in the ICU

NPs and PAs have been used in ICUs as a replacement for physicians in training or to provide on-site semiclosed staffing to care for critically ill patients. Data suggest that use of NPs and PAs is safe and equally efficacious for patient care

Kapu et al., 201420

Evaluation of impact of adding NP to the rapid response team

In 2011, the new teams responded to 898 calls, averaging 31.8 minutes per call. The most frequent diagnoses were respiratory distress (18%), postoperative pain (13%), hypotension (12%), and tachyarrhythmia (10%). The teams facilitated 360 transfers to intensive care and provided 3056 diagnostic and therapeutic interventions. Communication with the primary team was documented on 97% of the calls. After implementation, charge nurses were surveyed, with 96% expressing high satisfaction associated with enhanced service and quality

Kapu et al., 201420

Retrospective, secondary analysis of return on investment after adding NPs to 5 teams

Gross collections compared with expenses for 4 NP-led teams for 2-year time periods were 62%, 36%, 47%, and 32%. Average risk-adjusted LOS for the 5 time periods after adding NPs decreased and charges decreased

Kawar and DiGiovine, 201122

Comparison of clinical outcomes between patients admitted to a resident-run MICU and a PA-run MICU with retrospective analysis of prospectively collected data for 5346 patients admitted to an MICU from January 2004 through January 2007; 3971 patients were admitted to a resident-run MICU (resident group) and 1375 to a PA-run MICU (PA group)

There was no difference in hospital mortality or in ICU mortality between the two groups either in uncontrolled or controlled analyses. Survival analyses showed no difference in 28-day survival between the 2 groups

Landsperger et al., 201631

Among 9066 admissions, there was no difference in MICU prospective cohort study of all admissions to 90-day survival for patients cared for by ACNP or an adult medical ICU in an academic, tertiary-care resident teams (adjusted HR 0.94; 95% CI center during a single time period. The primary end 0.85–1.04; P 5 .21). Although patients cared for by point of 90-day survival was compared between ACNPs had lower ICU mortality (6.3%) than patients cared for by ACNP and resident teams resident team patients (11.6%; adjusted OR 0.77; using Cox proportional hazards regression. 95% CI 0.63–0.94; P 5 .01), hospital mortality was Secondary end points included ICU and hospital not different (10.0% vs. 15.9%; adjusted OR 0.87; mortality and ICU and hospital length of stay 95% CI 0.73–1.03; P 5 .11). ICU length of stay was similar between the ACNP and resident teams (3.4 6 3.5 days vs. 3.7 6 3.9 days [adjusted OR 1.01; 95% CI 0.93–1.1; P 5 .81]), but hospital length of stay was shorter for patients cared for by ACNPs (7.9 6 11.2 days) than for resident patients (9.1 6 11.2 days) (adjusted OR 0.87; 95% CI 0.80–0.95; P 5 .001)

McMillen et al., 201232

Surgical ICU care for 13,020 patients by PA team in 12-bed stepdown unit

Annual surgical mortality decreased and surgical volume increased Continued

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Critical Care Resource Use and Management

TABLE 86.2  Selected Studies on NP and PA Care in the ICU.—cont’d Study

Method/Focus

Main Results

Sirleaf et al., 201424

Comparison of procedures by NPs, PAs, and MDs for 1404 patients

MDs performed 1020 procedures, with 21 complications (complication rate 2%). NP/PAs completed 555 procedures; with 11 complications (complication rate 2%). There was no difference in the mean ICU and hospital LOS. Mortality rates were also comparable between the 2 groups (MD 11% vs. NP/PA 9.7%)

Sise et al., 201133

Prospective analysis of adding NPs to a level 1 trauma center. Analysis of demographics, injury severity scores, LOS, complications, total direct costs of care, and outcomes

After addition of NPs, a decrease in complications by 28.4%, LOS by 36.2, and costs of care by 30.4%

CI, confidence interval; HR, hazard ratio; ICU, intensive care unit; LOS, length of stay; MD, medical doctor; MICU, medical intensive care unit; NP, nurse practitioner; OR, odds ratio; PA, physician assistant; UTI, urinary tract infection.

BOX 86.2  NP- and PA-Performed Tasks

That Enhance the Quality of Care.15–26

Reduced length of stay Reduced rates of urinary tract infections Reduced rates of skin breakdown Reduced time to bladder catheter removal Reduced time to mobilization Reduced duration of mechanical ventilation Increased compliance with clinical practice guidelines Reduced rates of reintubation Increased time in coordination of care activities and costeffective care Increased patient and family satisfaction NP, nurse practitioner; PA, physician assistant.

CONCLUSIONS NPs and PAs are increasingly being integrated into ICUs. Care provided by teams that include NPs and PAs has been demonstrated to be comparable to that provided in other staffing models.29,30 Increasing patient acuity levels, burgeoning requirements for ICU care, and a need to have ICUtrained clinicians provide for critically ill patients presents an important opportunity to integrate NPs and PAs as ICU care providers. Continued dissemination of successful ICU staffing models integrating NPs and PAs as well as additional research on ICU staffing models that include NPs and PAs are needed to identify best strategies for promoting optimal care for critically ill patients. AUTHORS’ RECOMMENDATIONS • ICU models of care that incorporate NPs and PAs should be disseminated through publications and presentations to promote replication and extension. • Additional research that demonstrates the effect of NP and PA care for ICU patients is needed. • Funding should be allocated for research that explores optimal ICU workforce and staffing models that include NPs and PAs.

REFERENCES 1. Society of Critical Care Medicine. Critical Care Statistics. 2018. Available at: http://www.sccm.org/Communications/CriticalCare-Statistics. Accessed November 5, 2018. 2. The Leapfrog Group. Hospital Survey. Factsheet: ICU Physician Staffing. April 2018. Available at: http://www.leapfroggroup.org/sites/default/files/Files/2018%20IPS%20Fact%20 Sheet.pdf Accessed November 5, 2018. 3. Pastores SM, O’Connor MF, Kleinpell RM, et al. The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units. Crit Care Med. 2011;39:2540-2549. 4. Ward NS, Afessa B, Kleinpell R, et al. Intensivist/patient ratios in closed ICUs: a statement from the Society of Critical Care Medicine Taskforce on ICU Staffing. Crit Care Med. 2013; 41:638-645. 5. American Association of Nurse Practitioners. NP Fact Sheet. August 2018. Available at: http://www.aanp.org/all-about-nps/ np-fact-sheet. Accessed November 5, 2018. 6. American Academy of Physician Assistants. What is a PA? Available at: https://www.aapa.org/what-is-a-pa/. Accessed November 5, 2018. 7. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2010:638-645. 8. National Council of State Boards of Nursing. APRN Consensus Model. Chicago, IL: NCSBN; 2008. 9. Kleinpell R, Cook ML, Padden DL. American Association of Nurse Practitioners National Nurse Practitioner sample survey: update on acute care nurse practitioner practice. J Am Assoc Nurse Pract. 2018;30(3):140-149. 10. Kleinpell RM, Boyle WA III, Buchman TG, eds. Integrating Nurse Practitioners and Physician Assistants into the ICU: Strategies for Optimizing Contributions to Care. Mount Prospect, IL: Society of Critical Care Medicine; 2012. 11. Moote M, Krsek C, Kleinpell R, Todd B. Physician assistant and nurse practitioner utilization in academic medical centers. Am J Med Qual. 2011;26(6):452-460. 12. Curren J. Nurse practitioners and physician assistants: do you know the difference? Medsurg Nurs. 2007;16(6):404-407. 13. Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidencebased review. Crit Care Med. 2008;36(10):2888-2897.

CHAPTER 86 14. Gershengorn HB, Johnson MP, Factor P. The use of nonphysician providers in adult intensive care units. Am J Respir Crit Care Med. 2012;185(6):600-605. 15. Scherzer R, Dennis MP, Swan BA, Kavuru MS, Oxman DA. A comparison of usage and outcomes between nurse practitioner and resident-staffed medical ICUs. Crit Care Med. 2017;45(2): e132-e137. 16. Joffe AM, Pastores SM, Maerz LL, Mathur P, Lisco SJ. Utilization and impact on fellowship training of non-physician advanced practice providers in intensive care units of academic medical centers: a survey of critical care program directors. J Crit Care. 2014;29(1):112-115. 17. Gracias VH, Sicoutris CP, Stawicki SP, et al. Critical care nurse practitioners improve compliance with clinical practice guidelines in “semiclosed” surgical intensive care unit. J Nurs Care Qual. 2008;23(4):338-344. 18. Johal J, Dodd A. Physician extenders on surgical services: a systematic review. Can J Surg. 2017;60(3):172-178. 19. Woo BFY, Lee JXY, Tam WWS. The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: a systematic review. Hum Resour Health. 2017;15(1):63. 20. Kapu AN, Kleinpell R, Pilon B. Quality and financial impact of adding nurse practitioners to inpatient care teams. J Nurs Adm. 2014;44(2):87-96. 21. Paton A, Stein DE, D’Agostino R, Pastores SM, Halpern NA. Critical care medicine advanced practice provider model at a comprehensive cancer center: successes and challenges. Am J Crit Care. 2013;22(5):439-443. 22. Kawar E, DiGiovine B. MICU care delivered by PAs versus residents: do PAs measure up? JAAPA. 2011;24(1):36-41. 23. Gershengorn HB, Wunsch H, Wahab R, et al. Impact of nonphysician staffing on outcomes in a medical ICU. Chest. 2011;139(6):1347-1353.

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24. Sirleaf M, Jefferson B, Christmas AB, Sing RF, Thomason MH, Huynh TT. Comparison of procedural complications between resident physicians and advanced clinical providers. J Trauma Acute Care Surg. 2014;77(1):143-147. 25. Barocas DA, Kulahalli CS, Ehrenfeld JM, et al. Benchmarking the use of a rapid response team by surgical services at a tertiary care hospital. J Am Coll Surg. 2014;218(1):66-72. 26. Kapu AN, Wheeler AP, Lee B. Addition of acute care nurse practitioners to medical and surgical rapid response teams: a pilot project. Crit Care Nurse. 2014;34(1):51-59. 27. Perlmutter L, Nataraja S. Developing the Sustainable Critical Care Team. Washington, DC: Advisory Board Company Physician Executive Council; 2012. 28. McCarthy C, O’Rourke NC, Madison JM. Integrating advanced practice providers into medical critical care teams. Chest. 2013;143(3):847-850. 29. Garland A, Gershengorn HB. Staffing in ICUs: physicians and alternative staffing models. Chest. 2013;143(1):214-221. 30. Adams EK, Markowitz S. Improving efficiency in the healthcare system: removing anticompetitive barriers for advanced practice registered nurses and physician assistants. Brookings Institute, Policy Proposal 2018-08. 2018. 31. Landsperger JS, Semler MW, Wang L, Byrne DW, Wheeler AP. Outcomes of Nurse Practitioner-Delivered Critical Care: A Prospective Cohort Study. Chest. 2016 May;149(5):1146-54. 32. McMillen MA, Boucher N, Keith D, Gould DS, Gave A, Hoffman D. Maintaining quality of care 24/7 in a nontrauma surgical intensive care unit. J Trauma Acute Care Surg. 2012 Jul;73(1):202-8. 33. Sise CB, Sise MJ, Kelley DM, Walker SB, Calvo RY, Shackford SR, Lome BR, Sack DI, Osler TM. Resource commitment to improve outcomes and increase value at a level I trauma center. J Trauma. 2011 Mar;70(3):560-8.

e1 Abstract: Nurse practitioners (NPs) and physician assistants (PAs), collectively termed advanced practice providers (APPs), are increasingly being incorporated into intensive care unit (ICU) and acute care teams to meet the needs of acute and critically ill patients. Data from national surveys on the use of APPs indicate that utilization in hospital settings has increased because of the higher acuity of hospitalized patients, restrictions placed on medical resident work hours, the need for continuity of care, and workforce shortages. Role components of APPs include direct patient care management, diagnosing and treating illnesses, ordering and interpreting tests, initiating orders, prescribing and performing diagnostic,

pharmacologic and therapeutic interventions including performing procedures consistent with education, training, state regulations, and site-specific requirements. APP roles encompass other aspects of care, including participation in or leading the integration of clinical practice guidelines, quality improvement initiatives, clinical research, and education of patients, families, physicians in training, and clinical bedside nurses. Continued dissemination of successful ICU staffing models integrating APPs is needed to identify the best strategies for promoting optimal care for critically ill patients. Keywords: nurse practitioner, physician assistant, advanced practice provider, ICU, workforce, ICU team